Fall in an Aircast

A 40-year-old male with type 1 diabetes of 30 years' duration, proliferative retinopathy treated with laser photocoagulation, sensory neuropathy and autonomic neuropathy including postural hypotension, developed an acute right mid-foot Charcot's osteoarthropathy. Because of a previous episode of severe sepsis he was reluctant to wear a total-contact cast, but agreed to wear a removable Aircast. He suffered a fall in his home where the kitchen floor was covered with shiny linoleum and X-ray revealed a fracture of the tibial plateau which progressed to a Charcot's osteoarthropathy of the knee. A plaster of Paris cylinder was applied for 6 months, followed with a knee brace.

Key points

• Postural hypotension coupled with impaired proprioception makes patients unstable

• Unstable patients risk falls if they walk on shiny surfaces in a cast walker. However, this drawback also applies to total-contact casts and 'Scotchcast' boots

• Charcot's osteoarthropathy of the knee is rare. The authors have seen four cases, all of whom had previous Charcot's osteoarthropathy of mid-foot or hindfoot on the same side as the affected knee.

Temporary ready-made shoes

When it is not possible to provide a cast, ready-made temporary shoes with cushioning insoles that can accommodate dressings, or weight-relief shoes are helpful.

Dressing shoes

' The Darco shoe provides closed toe protection and room for bulky dressings. It can also be fitted with a Plastazote or bespoke moulded insole

• The Dru shoe is a Plastazote shoe which has two removable Plastazote insoles of medium and low density which mould to heat or pressure for a customized fit. It has Velcro fastening and can accommodate wound dressings.

Weight-relief shoes

• Orthowedge: this shoe off-loads pressure from the metatarsal head and toes using a rockerbottom wedge design

• Forefoot relief shoe: this transfers weight from forefoot to hindfoot with 10 degrees of dorsiflexion built into the shoe. A semi-rigid heel counter provides stability

• Heel relief shoe: this eliminates weightbearing on the posterior end of the foot, which is put into a plantar flex mode to facilitate off-loading of the heel area. Weight is transferred from heel to mid-foot and forefoot • Half shoe: the front area of the sole is 'cut away' to relieve pressure on the forefoot for forefoot ulceration and the posterior area of the sole is 'cut away' to relieve hindfoot pressure if the ulcer is on the heel. They are available off the shelf but can be customized.

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